There’s growing evidence that psychosis is linked to the physocal environments that we live in. Good environments are the ones that allow people to step back, relax and feel secure, while engaging in interesting and meaningful activity. Bad environments don’t allow respite: they keep people on their toes and somehow magnify meaninglessness and hollow rules and unreasonable demands. They may also be bleak and even unfair or outright scary. But don’t expect everyone to notice the bad environments: recent studies demonstrate that patients with psychosis are far more likely to notice even subtle negative features in the environment than people without symptoms. The same patients are also less likely to notice the good things an environment has to offer – but that doesn’t mean they shouldn1 be provided. Most mental health laccolites aren’t designed with recovery in mind: mental health facilities are first and foremost designed to improve the efficiency of the things that staff do. And for nurses, that means observations, report writing and patient-management. Architects
design for observation by making corridors that radiate from staff-stations. They design for report-writing by making the staff stations nicely glazed, so the clinical staff won’t be bothered by the consumers. A typical design response for patient-management is to pre-emptively restrict a patient’s actions: patients have to do things where they can be seen (by staff, in their stations) or not at all. And if patients misbehave, there’s always the threat of another design solution: seclusion. Thus many of the more harmful aspects of mental health facility design are presented as non-negotiable aspects of security procedures. established routines and treatment regimes. These solutions are staff-centered. not patient-centered because they create a single dynamic in a facility, which is to anchor the locus of control within the sealed confines of the staff station. And because the staff are powerful stakeholders in the design process, things re unlikely to change unless the families and other consumer champions advocate for change. (11 has to be advocates because consumers’ opinions are too easily written off as delusional) Thanks to enormous pressure from consumers and their carers, person-centered care is on the international agenda for mental healthcare facilities and the rhetoric is already all about recovery, but the stakeholder process ensures that the locus of control remains with the staff, and so the rhetoric is turned to empty words. often printed as slogans on the walls. But surely recovery comes first? Surely mental health facilities should be all about patients getting back on the or feet? For a long tome consumers have recognized
that mental health facilities aren1 great places to get better, but for the best part, they’re all there is. Consumers and carers want better: they advocate person-centered models of care, a consideration of the whole person, and a focus on recovery on the consumer’s own terms. But what does person-centered and recovery-centered focus mean for a facility, and why don’t current facilities enable such wholesome goals? Having worked for MMP (Medical Architecture) and specialized in mental health facilities since the 1980’s. we’ve conducted many stakeholder meetings with government, health authorities, clinicians and their union representatives, and heard the following arguments against patient-centred care: Too few staff: Most mental health facilities have more staff than patients. In ‘secure’ or ‘high dependency’ units there may bo 3 times more staff. Shortage of staff os therefore not the problem. it’s that staff are too specialized to engage in other activities. The prevailing paradigm is that opening the learning kitchen or pottery room in the evening or weekend will mean another occupational therapist
will be needed, when someone else could easily be up-skilled to provide basic
safety observation for everyday activities.
We want to calm the patients down, not excite them: Symptoms can’t always be addressed so directly, especially manoao. To some degree patients have to get what they want before they will calm down. The trick here is to channel desires through interesting things to do – 24f7 and not to remove opportunities for positive engagement.
Safety: Patients might eat the clay, hang themselves on a guitar string etc. A one-size-fits-all approach serves nobody. There will be some patients who are confused and others who are suicidal. The environment in most
mental health facilities is stripped down to a very small set of controlled circumstances to restrict both kinds of danger. But to strip the environment back to the point where it cannot meet clinical needs for recovery is like banning medicines in a hospital. There’s also a correlation between stays on restrictive environments and increased suicidal ideation.
Security: Patients will escape. Bizarrely, this concern is just as likely to be voiced for facilities where patients are self-admitted. The concern for security must be risk-managed holistically. it’s not solved simply by central staff stations and radial design, but by building trusting relationships between staff and patients. Also a rewarding and healing environment doesn’t invite patients to escape. Patients might be too happy: They will fake mental illness to get in. Anyone who fakes mental illness with the objective to stay longer in a mental health facility has a mental disorder worth treating. Yes, stays may get longer, but staff always have the power to discharge when it becomes appropriate. Also, it’s worth nothing that short stays (especially in highly restrictive facilities) have far higher suicide rates, both inside and within a month of leaving. Giving patients what they want is just feeding their delusions. Delusions are a framework for dealing with life’s circumstances and complexity. Denying or removing this crutch is dangerous and counterproductive during a period of crisis. it’s like choosing to remove a security blanket from a child after a traumatic event. In spite of this bombardment of reasons why things should stay the same as they’ve always been, at MMP we’ve always advocated tor more patient control and supported our stance with scientific evidence. What we’d like to see are facilities where the patients do wholesome and useful things with their time: facilities where there are veggie patches so patients can tend gardens and harvest their own work (or at least they can honor the labor of patients who went before them). They can cook for themselves and tor others, and clean up too. Just like in real life. In a facility in Canada, recovering patients have a cafe where they make cakes. Sandwiches, tea and coffee and other patients serve these goodies to the public. Others repair computers and others again run other businesses. And not only do patients enjoy the interaction with the community, they get paid for their efforts, and tips on top. Isn’t that what recovery-centered should mean? Of course one of the functions of a facility has to be respite. A place where people who have just had too much on their plates for too long should be able to take a break and be looked after. Why not? Why not take respite to prevent a melt down? How could a facility aid that? Oiler spaces to relax, to gaze at the sky and over beautiful views, to do easy and fun activities, games and sports. Why not make a facility that’s so good that patients can feel trusted – a facility where patients have buy-in? Perhaps then family and friends will want to visit, instead of finding excuses not to see their loved-ones? The service should then be dynamic and offer patients a choice: be active or just take a break. That’s what patient-centeredness is, because the patient’s needs are central. At MAAP we have strong evodence to suggest that innovation does work in mental health design. Yet probably the single obstacle to innovation is fear of change, which can be interpreted as fear of the patient. Indeed. facilities are designed so that even the basoc right ol safety is afforded primanly to staff. The staff station described earlier, woth its wall of glass, protects staff from largely imagined violence. it’s true. the risk of homicide in a mental health facility is higher than in most other places on a hospital. and that staff have the right to remain safe and when patients are out of control and dangerous, some degree of control or security is warranted. But what about the consumers? Don’t they have at least equal rights? Perhaps consumers have a greater need for physical security, considering the vulnerable state they’re on? Of the 11 homocodes in mental health inpatoent facilities in Australia and New Zealand between 1985-2010, tO of the victims were fellow patients. Also, the dynamics of radial design ensures that the power of self-determinatoon cannot be handed back when patients calm down. 1t is therefore incompatible with ideals of recovery-focus and patient-centeredness. Yet if designers wish to run with other options, the stakeholders and sometimes even the community very restrictive. Innovation clearly won’t come from the institutions, so it can only come from advocacy groups. 1t won1 come from institutions because stakeholders are invested in the status quo. They believe their own rhetoric for the need for facilities to remain as they ar e. Yet we have the knowledge and the tools to make facilities very good places to recover. All we need now is the political and institutional will to drive innovation and test the effects of a genuinely patient-centered and recovery- centered facility here in Australia.